1.03 Minor Head Trauma ("Concussion")

Presentation

A patient is brought to the ED after suffering a blow to the
head. There may or may not be a laceration, scalp hematoma, headache,
transient sleepiness and/or nausea, but there was NO loss of consciousness,
amnesia for the injury or preceding events, seizure, neurological changes, or
disorientation. The patient or family may express concern about a "mild
concussion," the possibility of a skull fracture, or a rapidly developing
scalp hematoma or "goose egg."

What to do:

Corroborate and record the history from witnesses. Ascertain why the
patient was injured (was there a seizure or sudden weakness?) and rule out
particularly dangerous types of head trauma. (A blow by a brick or hammer is
more likely to produce a depressed skull fracture.)

Perform and record a physical examination of the head, looking for signs of
a skull fracture, such as hemotympanum or bony depression, and examine the
neck for spasm, bony tenderness, rage of motion, and other signs of associated
injury.

Perform and record a neurological examination, with special attention to
mental status, cranial nerves, strength, and deep tendon reflexes to all four
limbs.

If the history or physical examination suggests there could be a clinically
significant intracranial injury, obtain a non-contrast computed tomogram (CT)
scan of the head. Criteria for obtaining a CT scan include: documented loss
of consciousness, amnesia, cerebrospinal fluid leaking from nose or ear, blood
behind the tympanic membrane or over the mastoid (Battle's sign), stupor,
coma, or any focal neurological sign.

If the history or physical examination suggests there could be a clinically
significant skull fracture, obtain skull x rays. Criteria for obtaining skull
x rays include: a blow by a heavy object, suspected skull penetration and
palpable depression.

If there is no clinical indication for CT scan or skull films, explain to
the patient and concerned family and friends why x-ray images are not being
ordered. Many patients expect x rays, but will gladly forego them once you
explain they are of little value.

Explain to the patient and responsible family or friends that the more
important possible sequelae of head trauma are not diagnosed with x rays, but
by noting certain signs and symptoms as they occur later. Make sure that they
understand and are given written instructions that any abnormal behavior,
increasing drowsiness or difficulty in rousing the patient, headache, neck
stiffness, vomiting, visual problems, weakness, or seizures are signals to
return to the ED immediately.

What not to do:

Do not skimp on the neurological examination or its documentation.

Do not be reassured by negative skull films, which do not rule out
intracranial bleeding or edema.

Discussion

The risks of late neurological sequelae (subdural hematoma,
seizure disorder, meningitis, post concussion syndrome, etc.) make good
followup essential after any head trauma; but the vast majority of patients
without findings on initial examination do well. It is probably unwise to
describe to the patient all of the subtle possible long-term effects of head
trauma, because many may be induced by suggestion. Concentrate on making sure
all understand the danger signs to watch for over the next few days. A large
scalp hematoma may have a soft central area which mimics a depression in the
skull when palpated directly, but allows palpation of the underlying skull
when pushed to one side. Cold packs may be recommended to reduce the swelling,
and the patient may be reassured that the hematoma will resolve over days to
weeks. Patients with minor head injuries who meet the criteria for a CT scan
but who have a normal scan and neurological examination may be safely
discharged from the ED.